Instructions for Completing a Report of Death Form to the Justice Center

General Instructions

Every Director (or their designee) of a residential facility or residential program operated, licensed or certified by the Office for People With Developmental Disabilities (OPWDD), the Office of Mental Health (OMH), the Office of Alcoholism and Substance Abuse Services (OASAS), or the Office of Children and Family Services (OCFS) is required to immediately report the death of a vulnerable person upon discovery (witnessing or learning) of such death. Report should be made no later than 24 hours after discovery. This immediate report of death shall be made by calling the Vulnerable Persons Central Register (VPCR) Death Reporting Line at 1-855-373-2124, which is separate from the VPCR Hotline to report abuse, neglect, and significant incidents.

After the initial report of death is made to the VPCR Death Reporting Line, every Director (or their designee) shall complete the designated Justice Center report of death as thoroughly as possible within five working days of the discovery of the death. This form can be found on the Justice Center website and may also be available within the operator’s State Oversight Agency (SOA) incident management system). Each field of the form should be completed to the best of the reporter’s knowledge. Some of the requested information may not be known or available at the time of completion. If information is not available, an explanation should be provided. An autopsy report for the decedent shall also be submitted to the Justice Center within 60 working days. The Justice Center may extend that timeframe if there being good cause shown.

Abuse & Neglect Reporting Requirement

If there is any reason to suspect abuse or neglect related to a death, this must be separately reported to the Vulnerable Person’s Central Registry (VPCR) Hotline at 855-373-2122 in accordance with the Justice Center mandated reporting requirements. Non-residential programs must also report suspected abuse or neglect related to a death to the VPCR hotline.

Required Reports of Death

Reports of death for individuals in the following facilities or programs are required:

The individual was receiving services from an Office for People With Developmental Disabilities (OPWDD) operated, licensed, or certified residential facility or residential program at the time of their death, or had received services within 30 days of their death.

The individual was receiving services from an Office of Mental Health (OMH) operated, licensed, or certified residential facility or residential program at the time of their death, or had received services within 30 days of their death.

The individual was receiving services from an Office of Alcoholism and Substance Abuse Services (OASAS) licensed or certified residential facility or residential program at the time of their death, or had received services within 30 days of their death.

The individual was receiving services at the time of their death, or had received services within 30 days of their death from the following: an Office of Children and Family Services (OCFS) operated residential facility or residential program for youth placed in the custody of the Commissioner of OCFS; was receiving services from an OCFS licensed or certified residential facility serving abandoned children, abused children, neglected children, dependent children, persons In need of supervision, or juvenile delinquents; was receiving services from an OCFS Family Type Home for Adults; was receiving services from an OCFS certified runaway and homeless youth program; or was receiving services from an OCFS certified youth detention facility.

In instances in which an individual received services from more than one provider agency, even if the provider agencies are licensed or certified by the same State Oversight Agency, only the residential provider agency must report the death to the Justice Center. (Example: an individual received residential services from Provider Agency A, and received mental health clinic services from Provider Agency B; only Provider Agency A is required to report the individual’s death to the best of their ability).

Distribution

Directors (or their designee) should submit the Justice Center Report of Death to the Executive Secretary, Mental Hygiene Medical Review Board. It is preferred that these forms be received via fax (518-457-3503), but can be submitted by mail to the NYS Justice Center for the Protection of People with Special Needs, at 401 State Street, Schenectady, NY 12305.

All facilities or programs should also ensure compliance with other applicable rules and regulations.

Specific Instructions

The beginning of the form requires entry of the Justice Center Incident Report Confirmation Number provided by the VPCR at the time of the initial report of death. Identifying information for the decedent at the time of their death (full name, DOB, age, gender, ethnicity, height, and weight) is also required.

Section 1: Reporting Agency/Facility/Program Data

This section requires essential information about the agency and the specific residential program that served the individual: the names, titles, and contact numbers for key agency personnel; the date in which the individual began receiving services from the facility or program; and, the SOA that operates, licenses, or certifies the facility or program (OPWDD, OMH, OASAS, or OCFS).

Section 2: Recipient Information

This section requires essential information about the individual, including their relationship to the reporting agency, the individual’s relationship to other known providers, existing diagnoses and medications being taken at the time of their death, and recent medical/psychiatric/substance abuse visits to an Emergency Room (ER) or required hospitalizations.

The information regarding the relationship between the agency and the individual attempts to distinguish the level of care that was provided to the individual, which could range from hospitalization/ institutionalization, to community residential, to outpatient services only. To complete this section select the choice that best describes the relationship between the agency and the decedent at the time of death. If the same agency provided a multitude of services to the individual, the most intensive treatment setting should be considered for completing this section. If the individual received any level of residential service, the type of program should also be indicated (examples: OPWDD residential programs: ICF, IRA; OMH residential programs: Article 28 Hospital, Article 31 Hospital, CR; OASAS Programs: Inpatient Rehab Service, MMTP; OCFS Programs: Secure Detention Center, RTC). This section also attempts to elicit information about other providers of service, if known.

All existing diagnoses (medical, substance abuse, and psychiatric) and medications prescribed to the individual at the time of their death should be accurately and completely identified in this section. If the corresponding ICD codes for the individual’s diagnoses are available they may be entered, but they are not required. Illnesses or conditions not diagnosed prior to the individual’s death, but discovered as a result of autopsy or medical examination, should not be recorded in this section. Additionally, the most recent ER visits and/or hospitalizations should be reflected in this section.

Section 3: Death Data

This section requires specific information regarding the individual’s death, including the medically determined manner and cause of the individual’s death, the location of the death, and potential occurrences immediately preceding the individual’s death.

The specific date of death, actual or pronounced time of death, and the address and classification of where the death occurred are requested in this section. It is understood that the level of service provided to the individual at the time of death will directly impact the agency’s ability to provide this information. While the actual time of the individual’s death is preferred, depending on the nature of the services delivered to the individual, an official pronounced time of death by a medical professional (or designee) may be the best information available. Likewise, the specific address of where the death occurred and the location classification will be completed to the best of the reporter’s ability. The location classifications are as follows:

Community (individual’s private residence, family member residence, general community location)

Hospital

Residence (operated, licensed, or certified residential setting)

Unknown (the specific location where the death occurred is unknown to the reporter)

The individual’s Cause of Death (COD) and Manner of Death (MOD) should be provided from a reliable source, preferably from a Death Certificate, Hospital Summary, or verbal report from a Coroner or Medical Examiner (ME). Unless directly specified on medical documentation, “Cardio-Pulmonary Arrest” should not be provided as a COD; Cardio-Pulmonary arrest occurs with every death. It is understood that this information may not be known or available, particularly for individuals who received non-residential services. If so, the unavailability of this information should be reflected in the form with an explanation; items should not be left blank.

The remaining information in this section of the form requires additional information regarding the immediate circumstances leading up to the individual’s death. Information as to whether the individual had legal Do Not Intubate (DNI)/Do Not Resuscitate (DNR) orders in place or had received emergency medication for behavioral/psychiatric reasons within 24 hours of the death should be easily identified by residential providers.

Section 4: Narrative Summary

This section requires specific information about the individual’s medical, psychiatric, and behavioral presentation 90 days prior to their death. Depending on the level of service provided to the individual, specific information is required regarding routine medical and psychiatric issues leading up to the individual’s death, supervision and diet safeguards in place for the individual during this time period, and an illustration of any major changes in service provision/treatment/functioning that occurred with the individual.

Information about the individual’s routine medical care will simply reflect the presence of the medical provider involvement with the individual and the most recent consultations with the provider. In most cases, identification of acute medical or psychiatric issues in the past 90 days will simply reflect the presence of the specified issues, except for weight gain/loss and change in bowel habits. These issues will require information regarding the severity of this condition change (example: the individual gained 35 pounds in the last 90 days; the individual was found to have a partial bowel obstruction 7 days prior to death).

Information about safeguards in place for the individual will include, but is not limited to, a description of any prescribed level of supervision the individual was receiving and any changes in that level of supervision (example: individual’s supervision level was increased from 15 minute checks to constant supervision two days prior to death due to increased number of behavioral episodes; individual was in a secure detention center and was visually monitored at all times except during night hours, when individual was secured in their bedroom).

Dietary information provided will be medically ordered precautions for the individual being served, as well as an initial assessment as to whether the dietary precautions were being followed at the time of the individual’s death.

Any identified changes to the individual’s services, treatment regimen, and functioning levels will be illustrated by both simple check boxes within the form, and should then also be described in the following narrative field. Any other information from the form that requires further clarification or explanation should be provided in this field, along with any other information that may be a factor in illustrating/explaining the circumstances and/or cause of the individual’s death. For sudden or unexpected deaths on an inpatient unit or in a residential setting, information about the condition of the body and environmental factors are often of importance to investigators and should be noted and recorded in this field.